Evaluating the effects of electronic health records system adoption on the performance of Malaysian health care providers

Electronic health records (EHRs) are created from integrated health information systems via secured computer networks. These networks are available to authorized care providers for consultation and exchange purposes across health care settings [1]. In Malaysia, the EHR or Total Hospital Information System (THIS), is used to create EHRs to ensure full automation of hospitals and coordinated care delivery among various providers [2]. However, due to policy restrictions, hospitals in Malaysia have been implementing a non-shareable EHR system operated by a single or multiple authorized care providers within a particular facility [3]. In this system, the medical records of patients cannot be taken or used outside the hospital.

As developed in 1993, the EHR system was begun under the Sixth Malaysian Plan at the Selayang Hospital in 1999. It encompassed the total system framework, i.e., clinical, imaging, and administrative functions. New care facilities developed under the Seventh Malaysian Plan included HIS implementation starting with the primary system. While the EHR system was initially only for those hospitals with more than 450 beds, several Ministry of Health (MoH) hospitals across the country had begun to incorporate EHRs starting from the year 2000 onward [4, 5]. With the Malaysia HIE (myHIX) project initiated in 2008, these IT hospitals have been progressing towards implementing health information exchange (HIE) in participated MoH hospitals and clinics to enable the secure and smooth sharing of demographics and patient information, such as discharge summaries, referral letters, lab results, and imaging reports, through virtual private networks and later via cloud platforms.

The benefits of EHR systems are recognized mainly to support more excellent care, reduce medical resources, and improve clinical decisions [6]. However, without systematic evaluation, the system use could negatively affect job performance of clinical staff. In Malaysian tertiary referral centers, the use of clinical care IS was found to contradict doctors' workflows, their task complexities, and their work environments [7]. The doctors appeared to resist using the systems due to an inconvenient interface and functions, which have created many data entry mistakes and medication errors [8].

In one study, a group of researchers [9] identified HIS critical success factors by systematically reviewing pertinent studies published over the past 20 years (1996–2015). The review uncovered that the human factor was the most critical dimension in achieving HIS adoption success. Another study concluded that the successful application of HIS depends on how well the technology is implemented and how its use improves healthcare providers and hospitals [10]. In another research, Mohamadali and Zahari [11] recognized the challenges in the implementation of HIS in the Malaysian health industry, including (a) workflow disruptions with changing and complicated processes, (b) lengthy training procedures for learning HIS handling, (c) low computer hardware and network connectivity, and (d) loss of interest of physicians and nurses for using HIS due to lack of IT skills. All these factors were found to contribute to decreased adoption levels and productivity. Therefore, the “fit” among systems, records, technical support service, and knowledge is crucial in supporting the widespread acceptance of EHR systems and healthcare personnel [10, 12, 13].

The problems stated above give rise to the following question: to what extent do the quality of EHR systems, records, support service, and knowledge positively influence the effective use and performance of Malaysian health care providers? Existing studies in the local context have focused on adopting and accepting the EHR system and vaguely evaluated the providers' performance in using the systems [10,11,12, 14]. This gap necessitates developing a practical model that allows Malaysian clinicians to use EHR systems to effectively improve their work performance effectively. Accordingly, the present study aimed to evaluate several quality predictors' effects based on the effective use of EHR systems on healthcare providers' performance in a post-implementation stage.

Quantitative researchers have commonly adopted the DeLone and McLean (D&M) models to evaluate IS effectiveness [15, 16]. This evaluation framework has been generally applied to assess how several success factors can positively affect individuals and organizations. However, the D&M models appear to be common. Therefore, additional assessments are required to identify other potential factors that can positively influence clinicians' performance in using the EHR systems. An EHR system can manage and disseminate information to share knowledge and advance clinical research across multiple interoperable systems. Hence, a quality evaluation of IS should integrate knowledge quality for completion [17]. The use of the D&M model is also irrelevant due to the mandatory use of the EHR system [4, 18]. Therefore, the model must be revised with an improved measure for IS user performance when it is compulsory [2]. In measuring the success of IS, the D&M models delineate user satisfaction. However, a high relationship exists among system quality, information quality, and personal effect of user satisfaction construct [19], thus the low explanatory capability due to recurring measures [20]. Based on these justifications, user satisfaction is excluded in the performance measurement of care providers, but actual use will be improved with effective use.

Sets of relationships among exogenous, mediating, and endogenous constructs of the proposed study model are illustrated in Fig. 1. Each path possesses a positive hypothesized effect. The model comprises three exogenous constructs adopted from the DeLone and McLean (D&M) models, namely, system quality, record quality improvement through information quality replacement, service quality [15, 16], and knowledge quality (new construct), which are used as quality predictors. The D&M models are more appropriate for the problems being studied, the technical characteristics, the functionalities of local EHR systems, and prediction of the final performance outcome of end-users (health care providers) than other IT acceptance and user models, such as the unified theory of acceptance and use of technology and technology acceptance models.

Proposed study model

The proposed study model evaluated the care provider effect at the individual level of analysis for those who deliver primary health care to patients by excluding the organizational impact framed in the conventional generic D&M Models. The organizational effect is more applicable in measuring the perceptions of IS success among diverse EHR stakeholders besides physicians and nurses. Hence, the effectiveness of the EHR system adoption is assumed when the primary care providers exhibit increased performance levels as predicted by the proposed predictors (system quality, record quality, service quality, knowledge quality, and effective use).

In a clinical setting, “system quality” refers to adequate IT infrastructure, system interoperability, perceived security concern, and compatibility of EHR systems with clinical tasks performed by care providers [21]. In this study, system quality is one of the quality factors used to measure care providers' effective use and performance. Second, record quality depends on timely access, consistency, standardization, accuracy, duplication prevention, and the completeness of EHRs generated from the system. Record term is preferred to information output because the former accurately describes the definition of EHRs as the repository of patient data available in digital format, which is stored, shared, secured, and accessed by authorized providers to support continuous and quality care [3, 22]. Examples of EHRs are patient treatment notes, images, laboratory test results, prescriptions, discharge summaries, patient histories, and medical reports [22]. Third, service quality denotes the quality of technical support delivered by EHR system vendors and internal IT personnel to measure effective use and clinician performance. As a newly proposed fourth exogenous construct, knowledge quality refers to the extent to which the health care providers can learn, create new knowledge, and apply what they have learned from an EHR system [17]. These can be done by consulting EHRs, clinician workflows, and best clinical practices, which can be applied to make the right decisions and solve patient problems. An enhanced effective use is identified as a mediator that enables clinicians to accomplish their clinical tasks without committing significant medical errors, misdiagnosis, or prescribing inaccurate medications.

In the execution of clinical operations, EHRs rely on IT facilities, which influences the quality of patient care [23]. Doctors’ professional practices can be enhanced with excellent network connectivity [24]. In essence, interoperability means an EHR system's capability to access, use, transmit, and exchange EHRs from multiple integrated systems [25]. The interoperability of systems enables timely access to patient records for the benefits of cost reduction, speedy treatment, prevention of duplicated tests, and gradual improvement of doctor-patient relationships [26]. In a clinical setting, system security is HIS capability to protect the users and records from unauthorized access and against virus and bug threats [27]. These records should be acquired, stored, preserved, and used correctly and safely for high-standard care delivery [28]. Compatibility of technology with the work environment and organizational culture of health care providers is critical during system adoption [29]. The user will recognize the relative advantage of a system, whether it suits his/her job or style. In addition to task and workflow compatibility, a system design must also comply with standardized clinical practice guidelines (CPGs) [18]. Hence, the related hypotheses are as follows:

System quality has a positive effect on the effective use of EHR systems.

System quality has a positive effect on the performance of health care providers.

EHR is a summarized version of patient health information compiled from the medical records [5]. Implementation of critical-care IS reduces documentation time and increases EHR quality and access time [30], positively affecting the system acceptance by doctors and nurses [7]. Similarly, physicians in intensive care units found that EHR use positively affects increased time spent on clinical review and documentation [31]. Thus, the related hypotheses are as follows:

Record quality has a positive effect on the effective use of EHR systems.

Record quality has a positive effect on the performance of health care providers.

The positive attitude, performance, and satisfaction of clinical staff will improve when service providers deliver a high-quality support service [32]. Notably, the frequency of technical assistance visits will positively improve the use of an EHR system and physicians' work quality [33]. Hence, the related hypotheses are as follows:

Service quality has a positive effect on the effective use of EHR systems.

Service quality has a positive effect on the performance of health care providers.

EHRs primarily aims to integrate knowledge from patient health information in averting medical errors, thereby simplifying the analysis, presentation, and use of knowledge from EHRs. Clinical knowledge is generated from tacit knowledge (experiences or professional practices of care providers), converted into the explicit or documented form of CPGs, clinical workflows, and EHRs [17, 34]. An EHR system generates EHRs and stores CPGs and clinical workflows that contain knowledge [35], increasing its quality through sound clinical decisions and improved task productivity of clinicians [5, 12]. Hence, the related hypotheses are as follows:

Knowledge quality has a positive effect on the effective use of EHR systems.

Knowledge quality has a positive effect on the performance of health care providers.

An integrated EHR system must enable physicians to complete their clinical tasks without making significant errors. Furthermore, its effective or extended use will positively affect physicians and medical practice [36]. The actual use of an EHR system that was previously measured on frequency or duration and extent of use has to be refined with effective use to achieve high individual and organization performance levels [37]. An effective system increases the needs, productivity, satisfaction, and motivation of clinicians to maximize the capabilities of the system [38]. Hence, the related hypothesis is as follows:

The effective use of EHR systems has a positive effect on the performance of health care providers.